title: Review article: the assessment and management of chronic severe gastrointestinal dysmotility in adults.
abstract: BACKGROUND
  The characterisation and management of chronic severe gastrointestinal (GI) dysmotility are challenging. It may cause intestinal failure requiring home parenteral nutrition (HPN).
  
  
  OBJECTIVE
  To review the presentation, aetiology, characterisation, management and outcome of chronic severe GI dysmotility, and to suggest a pragmatic management algorithm.
  
  
  METHODS
  PubMed search was performed up to December 2012 using appropriate search terms, restricted to human articles and reviewed for relevance. Segmental dysmotility, acute ileus, functional syndromes and non-English articles were excluded. Evidence and recommendations were evaluated using the GRADE system.
  
  
  RESULTS
  In total, 721 relevant articles were reviewed. A coherent and definitive picture is hampered by overlapping classification systems using multi-modal characterisation methods, subject to pitfalls and some requiring further validation. The literature is confined to case series with no randomised trials. Fewer than 20% undergo full thickness jejunal biopsy, which are otherwise labelled idiopathic. However, in studies with up to 80% biopsy rates, neuromuscular abnormalities may be found in 90%. Between 14% and 50% will require HPN, comprising 8-14% of all HPN patients, of which 2/3 are primary/idiopathic and 1/3 secondary, with scleroderma being the leading secondary cause. Ten-year  mortality ranges from 13% to 35% and is worst in elderly scleroderma patients. Management includes limited treatments for secondary causes, prokinetics, symptom palliation, psychological support, nutrition, hydration and judicious surgery.
  
  
  CONCLUSIONS
  Severe dysmotility often remains idiopathic. It is rarely possible to alter disease trajectory; consequently, prognosis may be poor. Multi-disciplinary teams in a specialist setting can improve outcomes. Graded recommendations are enumerated and a pragmatic algorithm is suggested.
authors.affiliation: Department of Gastroenterology, Salford Royal NHS Foundation Trust, Salford, UK; Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK.
authors.forename: P
authors.initials: P
authors.lastname: Paine
authors.forename: J
authors.initials: J
authors.lastname: McLaughlin
authors.forename: S
authors.initials: S
authors.lastname: Lal
mesh_terms: D000328:Adult; D000368:Aged; D000465:Algorithms; D000818:Animals; D001706:Biopsy; D002908:Chronic Disease; D005767:Gastrointestinal Diseases / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D005769:Gastrointestinal Motility; D006801:Humans; D016331:Parenteral Nutrition, Home / Q000379:methods*; D010348:Patient Care Team; D011379:Prognosis; D012720:Severity of Illness Index